ORIGINAL ARTICLE
The Impact of Insurance Instability on Health Service Utilization: Does Non-metropolitan Residence Make a Difference? Bronwyn E. Fields, MPH, RN; Janice F. Bell, PhD, MPH, MN; Sally Moyce, BSN, RN; & Jeri L. Bigbee, PhD, RN, FAAN Betty Irene Moore School of Nursing, University of California Davis, Sacramento, California
Abstract Disclosure: The authors report no conflicts of interest. For further information, contact: Bronwyn Fields, RN, MPH, Betty Irene Moore School of Nursing, University of California-Davis, 4610 X Street, Suite 4202, Sacramento, CA 95817; e-mail: [email protected]. doi: 10.1111/jrh.12077
Purpose: Discontinuous and no health insurance are major barriers to health care utilization. This paper examines if nonmetropolitan versus metropolitan residence is associated with differences in health care utilization in the face of insurance instability. Methods: A cross-sectional analysis of adults aged 18-64 years was conducted using the 2006-2010 Medical Expenditure Panel Survey data set (N = 61,039). Negative binomial regression was used to model measures of health service utilization (emergency room [ER] visits, inpatient discharges, office-based visits, dental care visits, prescriptions filled, home health visits) as functions of insurance continuity, adjusted for sociodemographic and health-related covariates. Models were stratified by metropolitan versus nonmetropolitan residence. Findings: Health insurance continuity was significantly associated with several measures of health service utilization, including more ER visits for individuals with gaps in health insurance (IRR [incident risk ratio] = 1.29; 95% CI: 1.16-1.42) and fewer inpatient discharges for individuals without insurance (IRR = 0.50; 95% CI: 0.43-0.57) when compared with individuals with continuous insurance. Individuals who were discontinuously insured or uninsured had significantly fewer office-based visits. They also had significantly fewer dental visits, prescription fills, and home health visits; moreover, the magnitudes of these associations were generally significantly greater for residents of nonmetropolitan areas. Conclusions: Insurance instability is associated with higher use of emergency services and reduced use of nonhospital health care services. Residents of nonmetropolitan areas with unstable or no insurance coverage may be at particular risk for reduced access and use of some health services relative to their counterparts living in metropolitan areas. Key words geography, health disparities, health services research, insurance, Medical Expenditure Panel Survey.
Life expectancy at birth is lower in rural areas of the United States than in urban areas, and the disparity is widening.1 People living in rural areas are at increased health risk, with higher morbidity and mortality than their urban counterparts,2,3 although there are examples of rural residence being associated with improved health outcomes or being insignificant compared to the impact of other sociodemographic variables on health
c 2014 National Rural Health Association The Journal of Rural Health 31 (2015) 27–34
status.4-6 Rural residents are also at higher risk of being uninsured, being uninsured for longer periods, and of having greater financial burdens associated with outof-pocket health care costs than urban residents.7-9 The absence of health insurance is associated with negative health outcomes.10 Adults with chronic illnesses, cancer, or serious injury experience lower quality of life, higher morbidity, and mortality if they are uninsured.10,11
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Insurance Instability and Rural Residence
In 2011, 22% of the nonelderly US population were uninsured.9 The proportion of the general population with interrupted or discontinuous insurance is less clearly defined, but among adults insured under Medicaid, 46% had at least one gap in insurance coverage during a 2-year period.12 Being uninsured or discontinuously insured is a major barrier to accessing health care, and it is associated with not having a usual health care provider, delays in obtaining needed health care, lower levels of preventive care, and failure or delay in filling medication prescriptions.13-18 Kenney and associates found that more than half of uninsured adults aged 19 to 64 years in the United States did not see a health care provider in 2010, 46% reported unmet medical needs, 40% reported unmet dental needs, and only 38% had a usual health care provider.13 Differences in health care access between those with and without health insurance have been extensively studied, but there has been less exploration of the impact that interruptions in health insurance have on appropriate use of health services. Among those with Medicaid coverage, insurance instability is associated with more emergency room (ER) visits, hospitalizations and office visits, and fewer prescriptions filled.12 Adults with interruptions in insurance coverage are more likely to discontinue essential medications, such as antihypertensive drugs.15,18 A study of Medicaid recipients in California found that interruptions in insurance coverage are associated with increased risk of hospitalization for heart failure, diabetes, and chronic obstructive pulmonary disease.19 No studies have explicitly addressed potential differences in health service utilization by insurance discontinuity among rural versus urban individuals. Living in a rural area may be associated with increased delays in receiving needed health care or prescription drug refills, reduced utilization of some preventive care services, increased use of the ER, and increased levels of hospitalization.9 The purpose of this study was to measure associations between insurance discontinuity and health service utilization for the nonelderly adult population in the United States, and to test the extent to which the estimates differ for residents of urban and nonurban areas. The specific hypotheses tested were: (1) Insurance instability is associated with increased ER visits, increased hospitalizations, decreased prescription drug fills, and fewer formal home health provider days; and (2) The impact of insurance instability on utilization of health services is different for individuals living in nonmetropolitan statistical areas (non-MSAs) than for individuals living in metropolitan statistical areas (MSAs).
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Fields et al.
Methods This cross-sectional study used pooled data from the 2006 to 2010 Medical Expenditure Panel Survey Household Component (MEPS HC), which includes a nationally representative sample of the civilian, noninstitutionalized population in the United States. Given the relatively small number of observations reporting rural residence, 5 years of MEPS data were combined to ensure stable estimates. The MEPS HC survey, sponsored by the Agency for Healthcare Research and Quality (AHRQ), collected data in 5 in-person interviews over a 2-year period with 1 respondent reporting for all members of the household. In the years 2006 to 2010, data were collected from between 29,370 and 34,920 individuals annually, with annual response rates between 53.5% and 59.3%.20 MEPS HC data are publicly available and the study was deemed not to be research involving human subjects by the University of California Davis Institutional Review Board. Adults aged 18 to 64 years were eligible for inclusion in the study (N = 61,039). Older adults were excluded because few were expected to have gaps in health insurance coverage given their eligibility for Medicare. Cases were excluded from the analysis if data were missing for the dependent variables of interest (
The Impact of Insurance Instability on Health Service Utilization: Does Non-metropolitan Residence Make a Difference? Bronwyn E. Fields, MPH, RN; Janice F. Bell, PhD, MPH, MN; Sally Moyce, BSN, RN; & Jeri L. Bigbee, PhD, RN, FAAN Betty Irene Moore School of Nursing, University of California Davis, Sacramento, California
Abstract Disclosure: The authors report no conflicts of interest. For further information, contact: Bronwyn Fields, RN, MPH, Betty Irene Moore School of Nursing, University of California-Davis, 4610 X Street, Suite 4202, Sacramento, CA 95817; e-mail: [email protected]. doi: 10.1111/jrh.12077
Purpose: Discontinuous and no health insurance are major barriers to health care utilization. This paper examines if nonmetropolitan versus metropolitan residence is associated with differences in health care utilization in the face of insurance instability. Methods: A cross-sectional analysis of adults aged 18-64 years was conducted using the 2006-2010 Medical Expenditure Panel Survey data set (N = 61,039). Negative binomial regression was used to model measures of health service utilization (emergency room [ER] visits, inpatient discharges, office-based visits, dental care visits, prescriptions filled, home health visits) as functions of insurance continuity, adjusted for sociodemographic and health-related covariates. Models were stratified by metropolitan versus nonmetropolitan residence. Findings: Health insurance continuity was significantly associated with several measures of health service utilization, including more ER visits for individuals with gaps in health insurance (IRR [incident risk ratio] = 1.29; 95% CI: 1.16-1.42) and fewer inpatient discharges for individuals without insurance (IRR = 0.50; 95% CI: 0.43-0.57) when compared with individuals with continuous insurance. Individuals who were discontinuously insured or uninsured had significantly fewer office-based visits. They also had significantly fewer dental visits, prescription fills, and home health visits; moreover, the magnitudes of these associations were generally significantly greater for residents of nonmetropolitan areas. Conclusions: Insurance instability is associated with higher use of emergency services and reduced use of nonhospital health care services. Residents of nonmetropolitan areas with unstable or no insurance coverage may be at particular risk for reduced access and use of some health services relative to their counterparts living in metropolitan areas. Key words geography, health disparities, health services research, insurance, Medical Expenditure Panel Survey.
Life expectancy at birth is lower in rural areas of the United States than in urban areas, and the disparity is widening.1 People living in rural areas are at increased health risk, with higher morbidity and mortality than their urban counterparts,2,3 although there are examples of rural residence being associated with improved health outcomes or being insignificant compared to the impact of other sociodemographic variables on health
c 2014 National Rural Health Association The Journal of Rural Health 31 (2015) 27–34
status.4-6 Rural residents are also at higher risk of being uninsured, being uninsured for longer periods, and of having greater financial burdens associated with outof-pocket health care costs than urban residents.7-9 The absence of health insurance is associated with negative health outcomes.10 Adults with chronic illnesses, cancer, or serious injury experience lower quality of life, higher morbidity, and mortality if they are uninsured.10,11
27
Insurance Instability and Rural Residence
In 2011, 22% of the nonelderly US population were uninsured.9 The proportion of the general population with interrupted or discontinuous insurance is less clearly defined, but among adults insured under Medicaid, 46% had at least one gap in insurance coverage during a 2-year period.12 Being uninsured or discontinuously insured is a major barrier to accessing health care, and it is associated with not having a usual health care provider, delays in obtaining needed health care, lower levels of preventive care, and failure or delay in filling medication prescriptions.13-18 Kenney and associates found that more than half of uninsured adults aged 19 to 64 years in the United States did not see a health care provider in 2010, 46% reported unmet medical needs, 40% reported unmet dental needs, and only 38% had a usual health care provider.13 Differences in health care access between those with and without health insurance have been extensively studied, but there has been less exploration of the impact that interruptions in health insurance have on appropriate use of health services. Among those with Medicaid coverage, insurance instability is associated with more emergency room (ER) visits, hospitalizations and office visits, and fewer prescriptions filled.12 Adults with interruptions in insurance coverage are more likely to discontinue essential medications, such as antihypertensive drugs.15,18 A study of Medicaid recipients in California found that interruptions in insurance coverage are associated with increased risk of hospitalization for heart failure, diabetes, and chronic obstructive pulmonary disease.19 No studies have explicitly addressed potential differences in health service utilization by insurance discontinuity among rural versus urban individuals. Living in a rural area may be associated with increased delays in receiving needed health care or prescription drug refills, reduced utilization of some preventive care services, increased use of the ER, and increased levels of hospitalization.9 The purpose of this study was to measure associations between insurance discontinuity and health service utilization for the nonelderly adult population in the United States, and to test the extent to which the estimates differ for residents of urban and nonurban areas. The specific hypotheses tested were: (1) Insurance instability is associated with increased ER visits, increased hospitalizations, decreased prescription drug fills, and fewer formal home health provider days; and (2) The impact of insurance instability on utilization of health services is different for individuals living in nonmetropolitan statistical areas (non-MSAs) than for individuals living in metropolitan statistical areas (MSAs).
28
Fields et al.
Methods This cross-sectional study used pooled data from the 2006 to 2010 Medical Expenditure Panel Survey Household Component (MEPS HC), which includes a nationally representative sample of the civilian, noninstitutionalized population in the United States. Given the relatively small number of observations reporting rural residence, 5 years of MEPS data were combined to ensure stable estimates. The MEPS HC survey, sponsored by the Agency for Healthcare Research and Quality (AHRQ), collected data in 5 in-person interviews over a 2-year period with 1 respondent reporting for all members of the household. In the years 2006 to 2010, data were collected from between 29,370 and 34,920 individuals annually, with annual response rates between 53.5% and 59.3%.20 MEPS HC data are publicly available and the study was deemed not to be research involving human subjects by the University of California Davis Institutional Review Board. Adults aged 18 to 64 years were eligible for inclusion in the study (N = 61,039). Older adults were excluded because few were expected to have gaps in health insurance coverage given their eligibility for Medicare. Cases were excluded from the analysis if data were missing for the dependent variables of interest (
